Basic Information
| Provider Information | |||||||||
| NPI: | 1659341717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERZAPF | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | BAUDAT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 16605 SOUTHWEST FWY STE 400 | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774793500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812750800 | ||||||||
| FaxNumber: | 2812750801 | ||||||||
| Practice Location | |||||||||
| Address1: | 16605 SOUTHWEST FWY STE 400 | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774793500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812750800 | ||||||||
| FaxNumber: | 2812750801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | K5509 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 045860603 | 05 | TX | MEDICAID | 045860604 | 05 | TX | MEDICAID | 045860602 | 05 | TX | MEDICAID | 8EF695 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 045860601 | 05 | TX | MEDICAID | 080165741 | 01 | TX | RAILROAD MEDICARE | OTHER | 1659341717 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 8CE139 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |